An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?
Rationale:
The emotional quality of attitude is most important to compare before and after taking the antidepressant. Monitoring changes in mood directly reflects the medication’s effectiveness in alleviating depressive symptoms and helps detect any worsening or emergence of suicidal ideation, which is critical for ensuring patient safety and guiding further treatment adjustments.
A: Level of activity tracks physical movement but may not accurately reflect mood improvements or emotional changes, which are central to antidepressant efficacy in managing depression.
B: The interactions with others indicate social behavior but can be influenced by external factors and might not directly correlate with the internal emotional changes targeted by the medication.
D: Appetite changes can occur with antidepressants but are less specific indicators of mood improvement compared to shifts in emotional quality or attitude.
An adult client presents to the community mental health center accompanied by the client's spouse who reports that the client has been acting impulsively. The client has spent a large amount of money lately, made several last-minute decisions to take trips, sleeps only 2 to 4 hours a night, and has lost 33 pounds (15 kg) in the last 2 months. Which nursing problem has the greatest nursing priority?
Rationale:
Risk for self-directed violence related to impulsive behavior has the greatest nursing priority. This is because impulsivity combined with significant behavioral changes increases the likelihood of self-harm or dangerous actions, requiring immediate attention to ensure client safety and prevent potential injury or suicide attempts in a mental health crisis.
A: Sleep deprivation related to state of hyperactivity addresses rest issues but neglects immediate safety concerns posed by impulsive and risky behaviors that could result in harm or injury.
B: Ineffective coping related to biochemical changes focuses on adaptation difficulties but overlooks the urgent need to manage impulsivity and prevent potential self-directed violence or harm.
D: Imbalanced nutrition related to caloric expenditure highlights weight loss but does not prioritize the imminent risk posed by impulsive actions and possible self-harm behaviors.
A young adult male client is admitted to the psychiatric unit because of a recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in this client's plan of care?
Rationale:
Encourage activities that allow the client to exert control over his environment. This approach empowers the client to regain a sense of autonomy and self-efficacy, which is crucial after multiple losses. Structured activities reduce feelings of helplessness and improve mood, supporting recovery by fostering resilience and promoting active engagement in the healing process during psychiatric care.
A: Avoid discussing subjects that upset the client. Evading difficult topics limits emotional processing and therapeutic rapport, hindering the client’s ability to confront and manage distressing feelings essential for healing.
C: Allow the client time alone to sort out his feelings. Excessive isolation may increase feelings of loneliness and despair, potentially worsening depressive symptoms and suicide risk instead of facilitating constructive emotional coping.
D: Encourage the client to interact with persons who are recovering from depression. While peer support can be beneficial, immediate focus should be on individualized interventions that build control and stability before group interactions.
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?
Rationale:
The nurse should review the Abnormal Involuntary Movement Scale (AIMS).
The AIMS is specifically designed to detect and monitor tardive dyskinesia and other involuntary movements caused by psychotropic medications. It provides a standardized method to evaluate the severity and progression of these side effects, ensuring appropriate clinical interventions and medication adjustments are made to manage the client’s symptoms effectively.
A: The healthcare provider's history and physical lacks specific focus on involuntary movement assessments tied to psychotropic side effects.
B: Recent urine drug testing (UDT) identifies substance use but does not measure or evaluate involuntary motor symptoms related to medication side effects.
C: Baseline nursing admission assessment documents initial status but does not provide ongoing monitoring of movement disorders caused by psychotropic drugs.
When a male client is asked about his reason for coming to the mental health clinic, he replies, “It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me.†Which response should the nurse provide?
Rationale:
The nurse should respond with, "Have the feelings associated with these events brought you to the clinic?" This question directly addresses the client’s emotional experience, encouraging exploration of feelings and reasons for seeking help, which is essential in mental health assessment and establishing rapport.
A: Why do you think you have a hostile work environment? This question may sound accusatory and shifts focus from the client’s feelings to justification of the situation, which can hinder emotional expression.
B: Have you considered resigning from your position? Suggesting resignation prematurely overlooks the client’s emotional state and might imply avoidance rather than addressing underlying mental health concerns.
D: How have you responded to those in your work environment about these events? This question diverts attention to actions taken instead of exploring the client’s emotional impact, potentially neglecting important therapeutic dialogue.
The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?
Rationale:
The medication that should also be discontinued is Benztropine.
Benztropine is prescribed to manage extrapyramidal symptoms caused by antipsychotic medications; once the antipsychotic is stopped, the risk of these side effects diminishes, making continued benztropine unnecessary and potentially harmful due to its anticholinergic side effects.
A: Alprazolam is an anxiolytic used for anxiety, unrelated to antipsychotic side effects or discontinuation protocols.
B: Lithium is a mood stabilizer essential for bipolar disorder management and is not linked to the antipsychotic discontinuation process.
D: Magnesium is a mineral supplement without a direct connection to antipsychotic medication or its cessation.
The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client's history should the nurse further explore?
Rationale:
Violent nightmares are often linked to alcohol use, which can disrupt normal sleep patterns and provoke vivid, distressing dreams. Alcohol affects the brain’s neurotransmitters, increasing the likelihood of nightmares. The nurse should explore alcohol consumption to identify a possible cause of the client’s violent nightmares and guide appropriate interventions or referrals for treatment to improve sleep quality and mental health.
A: Family history of dementia does not typically correlate with violent nightmares; dementia primarily involves cognitive decline, not sleep disturbances of this nature. B: Witness to an accident might cause trauma-related symptoms but is less directly associated with violent nightmares than substance use. D: Inadequate diversional activity affects mood but rarely results in violent nightmares specifically linked to neurochemical changes.
While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?
Rationale:
Confidentiality will be maintained, except when one's safety is threatened. This response accurately reflects legal and ethical standards in mental health care, emphasizing client privacy while acknowledging exceptions related to safety concerns. It reassures the client about privacy but also informs them about mandatory disclosures, fostering trust and transparency in the therapeutic relationship without compromising legal responsibilities.
A: Provide the client with a written hospital policy regarding privacy of information laws. Offering written policies may inform but fails to directly address the client’s immediate concern about confidentiality and safety exceptions in a clear, empathetic manner. This approach lacks the personal reassurance essential in establishing trust during initial client interactions.
C: Nod in the affirmative, but make no verbal commitment to the client. Nonverbal agreement without explicit communication creates ambiguity and may increase client anxiety. It does not clarify confidentiality boundaries or exceptions, potentially undermining trust and leaving the client uninformed about critical privacy issues.
D: Assure the client that information provided will be shared with the staff only. This statement omits mentioning exceptions related to safety threats, which are crucial. It provides incomplete information, possibly misleading the client regarding the full scope of confidentiality and mandatory reporting laws.
An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement?
Rationale:
The most important intervention is to advise the mother to call the police if violent behavior occurs again. This action ensures immediate safety and legal involvement, addressing potential escalation and protecting both the adolescent and others. It aligns with the court order context and the serious nature of aggressive outbursts, prioritizing crisis management over emotional or therapeutic discussions at this stage.
B: Referring the mother for psychiatric evaluation overlooks the urgent need to manage the adolescent’s violent behavior and does not directly address the immediate risk or safety concerns related to the incident.
C: Reinforcing therapy attendance ignores the immediate safety risk posed by the violent outburst and fails to provide a direct action plan for the mother to manage potential future violence.
D: Advising the mother to share feelings with her son neglects the adolescent’s aggressive conduct and does not establish boundaries or safety measures necessary after such destructive behavior.
An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?
Rationale:
The nurse should assist the client in developing an emergency safety plan. This proactive approach prioritizes the client’s immediate safety, equipping him with strategies and resources to respond effectively to potential or ongoing abuse. It addresses the urgent risk posed by the son's increasing violence, enabling the client to protect himself and seek help promptly in dangerous situations.
A: Tell the client to call Adult Protective Services if his son's abuse continues. This response delays immediate safety measures and relies on client initiation rather than providing direct support to manage imminent danger.
B: Verify the client's report by determining if there is physical evidence of abuse. Confirming abuse is important but secondary to ensuring the client's immediate protection and safety.
C: Refer the client to a program for victims of domestic violence. Referral is helpful but insufficient without first establishing a concrete safety plan tailored to the client’s urgent risk and environment.
A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?
Rationale:
Support the client to list small behavioral changes needed. This approach aligns with motivational interviewing principles, encouraging gradual, achievable steps that foster self-efficacy and commitment. It respects the client’s readiness for change within a short timeframe, promoting empowerment and realistic goal-setting. This method increases the likelihood of sustained progress by focusing on manageable, specific behaviors rather than overwhelming the client.
B: Explain the specific skills needed to prevent a relapse. This prematurely focuses on relapse prevention skills without first establishing the client’s readiness or motivation, which may overwhelm or discourage them early in the change process.
C: Provide teaching on the symptoms of substance use dependence. Educating about dependence symptoms overlooks the client’s expressed desire for change and fails to directly support practical steps toward healthier behaviors.
D: Advise the client to reschedule until committing to recovery. This dismissive response neglects the client’s current motivation and may damage rapport, hindering engagement and delaying essential support during a crucial readiness phase.
A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client's plan of care? (Select all that apply)
Rationale:
Shielding the client from direct sunlight when outdoors and gradually withdrawing the medication over several days are essential interventions during haloperidol dosage reduction. Haloperidol increases photosensitivity, so sun protection prevents skin damage. Gradual tapering avoids withdrawal symptoms and relapse, ensuring a safer transition to a lower maintenance dose while monitoring the client’s response carefully throughout the process.
C: Enforcing a fluid restriction during dosage adjustment is unnecessary as haloperidol does not typically cause fluid retention or electrolyte imbalances requiring such measures.
D: Increasing the dosage if the white blood cell count drops is inappropriate; haloperidol can cause leukopenia, so dosage should be reduced or stopped, not increased, to prevent complications.
During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn't I use it? Which response is best for the nurse to provide?
Rationale:
Marijuana use alters one’s ability to think clearly, which can endanger both the user and those around them.
B: This response addresses the immediate safety concerns linked to marijuana’s cognitive effects, emphasizing real risks rather than debating addiction or morality, making it the most practical and relevant answer for a student’s question about usage consequences.
A: Marijuana is not universally classified as highly addictive, so stating this may mislead students about its dependency potential rather than focusing on actual risks.
C: Mentioning medical prescriptions diverts from the question about recreational use and does not counter the student’s claim about addiction.
D: Moral considerations are subjective and less effective in addressing the student’s practical concern regarding safety and health risks.
Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?
Rationale:
Determine the client's reason for attempting suicide has the highest priority at this time. Understanding the underlying cause of the suicide attempt is essential for effective mental health assessment, intervention planning, and preventing future attempts. Once the immediate physical danger is addressed, addressing psychological factors becomes crucial to ensure comprehensive care and patient safety in both short and long term.
B: Obtain the client's serum hydrocodone/acetaminophen level does not address immediate psychological needs and is less urgent after naloxone reversal and client stabilization. Lab values provide delayed information without immediate impact on mental health care.
C: Encourage the client to increase fluid intake is a general supportive measure but does not directly address the priority of assessing the client’s mental state and suicide risk following overdose recovery.
D: Observe the client for further narcotic effects is important initially but the client is already alert and oriented, making psychological evaluation a more critical focus at this stage.
The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?
Rationale:
The nurse should ask the adolescent sitting on the couch to join the group at the table. This arrangement promotes equal participation and facilitates face-to-face communication, which is essential for teaching assertive communication skills. Bringing all members physically closer encourages engagement, eye contact, and reduces social barriers, fostering a more inclusive and interactive learning environment among the adolescents.
A: Allowing adolescents to sit wherever they wish may lead to physical separation, diminishing group cohesion and reducing opportunities for effective communication and interaction during the session.
B: Suggesting they all sit together encourages interaction but lacks specificity; it does not address the current seating arrangement that separates one adolescent, limiting group engagement.
D: Determining who wants to participate does not address physical positioning, which is crucial for fostering assertive communication and equal involvement in group discussions.
An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?
Rationale:
Encouraging the adolescent to select an arts and crafts activity promotes engagement and self-expression without triggering anxiety related to weight or food. This intervention supports therapeutic involvement in a non-threatening, creative manner, fostering emotional regulation and distraction from disordered eating behaviors. It aligns with safe, holistic care principles for eating disorder patients in psychiatric settings.
A: Encourage the client to weigh herself daily at bedtime. Daily weighing can increase obsession with weight and exacerbate anxiety, reinforcing negative body image and disordered eating patterns, which is counterproductive in treatment.
B: Recommend exercise and recreation in the morning. Exercise may increase compulsive behaviors or caloric expenditure concerns in eating disorder patients, potentially worsening symptoms rather than promoting healthy recovery.
D: Put the client in charge of choosing snacks for the unit. Allowing control over snacks can trigger restrictive or binge behaviors, undermining structured nutritional plans essential for stabilization and recovery.
A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?
Rationale:
Feeling sad often is a core symptom of depression that helps differentiate it from other causes of fatigue and poor concentration. Asking about sadness directly targets emotional state, essential for diagnosing depression. This question provides critical insight into the client’s mood and emotional health, enabling the nurse to identify depressive symptoms beyond physical complaints like sleep problems or stress factors.
A: Have you experienced recent stresses? This explores external pressures but does not specifically assess depressive symptoms, making it less precise for identifying clinical depression.
B: What foods do you like to eat? This question relates to dietary preferences without direct relevance to depression diagnosis or emotional state assessment.
D: Have you experienced sleep changes? Sleep issues are common but nonspecific symptoms in depression; this question alone doesn’t capture the emotional core necessary for diagnosis.
A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?
Rationale:
The statement "Stop taking the medication if the intended effect is not immediate" requires additional instruction by the nurse. Lorazepam may not produce immediate relief, and abrupt discontinuation can cause withdrawal or rebound anxiety. Patients should be educated on proper use, gradual onset of action, and adherence to prescribed doses rather than stopping prematurely for safety and effectiveness.
A: Use relaxation techniques to reduce excessive anxiety supports holistic management and complements lorazepam’s effects, promoting overall anxiety reduction without conflict or contraindication.
B: Avoid alcohol and other sedatives while taking the medication prevents dangerous respiratory depression and excessive sedation, ensuring patient safety during lorazepam therapy.
C: Move slowly from a sitting position to a standing position helps prevent orthostatic hypotension, a common side effect of lorazepam, reducing fall risk and dizziness.
A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?
Rationale:
The nurse should first listen to what the client is saying. Listening allows the nurse to assess the client’s current state, understand the content and severity of hallucinations, and determine the appropriate intervention. This initial step prioritizes safety and therapeutic communication, helping to de-escalate the situation and gather essential information before taking further action or administering medication.
A: Sit in the chair next to the client. Sitting nearby may invade personal space prematurely, potentially escalating agitation rather than calming the client. Immediate proximity without assessment could increase distress or confusion.
C: Escort the client to his room. Moving the client without first understanding his condition risks escalating agitation and may violate his autonomy. Assessment should precede relocation to ensure safety and cooperation.
D: Administer a PRN sedative. Immediate medication without assessment overlooks the client’s current mental status and may unnecessarily sedate, bypassing less invasive, therapeutic communication strategies essential for safe management.
While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client's tongue is “wormingâ€Â. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?
Rationale:
The most important additional assessment is dentures to determine if they are poorly fitted. Poorly fitting dentures can cause tongue movement abnormalities and speech difficulties, especially in clients with schizophrenia who may already have impaired neuromuscular control. Evaluating the fit of dentures helps identify a mechanical cause for the tongue "worming" and articulation problems, guiding appropriate intervention to improve oral function and communication.
A: Usual level of activity and average sleep pattern offers insight into general health but does not address the specific oral or speech-related issues observed in this client.
B: Blood pressure when sitting and standing is vital for cardiovascular assessment but unrelated to tongue movement or articulation problems caused by dentures.
D: Body weight over the past three months reflects nutritional status but fails to explain the mechanical or neuromuscular causes of tongue “worming” and speech difficulty.
A young adult female client is admitted to the Emergency Department after being raped in a shopping center parking lot. The client expresses no suicidal ideation but expresses feelings of self-blame for not taking precautions when going to her car. According to theorists, such as Maslow and Erikson, this client is struggling with which issue?
Rationale:
This client is struggling with self-esteem.
Self-esteem involves the feelings of self-worth and value, which are impacted when the client blames herself for the assault. Maslow’s hierarchy and Erikson’s stages emphasize the importance of a healthy self-esteem for psychological well-being, especially after trauma, making self-esteem the central issue in her emotional response and recovery process.
A: Self-absorption focuses on excessive self-interest, which does not align with her expressed self-blame and emotional turmoil.
B: Self-actualization represents achieving full potential, unrelated to her current struggle with feelings of inadequacy and blame.
C: Self-control pertains to regulating impulses, not the diminished self-worth and guilt she is experiencing.
A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?
Rationale:
Allow the client to rest and sleep. Ensuring adequate rest is crucial as sleep deprivation can worsen depressive symptoms and impair cognitive function. Prioritizing sleep within the first 24 hours stabilizes mood and enhances the client’s ability to engage in further therapeutic interventions, promoting overall recovery and emotional regulation during the initial treatment phase.
B: Begin planning for the client's discharge focuses on long-term goals rather than immediate stabilization, neglecting the urgent need to address sleep deprivation and acute emotional distress during early treatment.
C: Encourage verbalization of feelings supports emotional expression but fails to address the critical immediate need for restorative sleep, which directly impacts mood regulation and mental health stabilization.
D: Ensure the client attends groups addressing coping skills for dealing with depression is premature without first stabilizing the client’s sleep and mood, which are foundational for effective participation in therapeutic groups.
During a one-to-one session with the nurse, a female client admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don't remember, but my mother ran my father off when I was five.†The nurse should recognize that the client may be using which defense mechanism?
Rationale:
The nurse should recognize that the client may be using repression. Repression involves unconsciously blocking out painful or traumatic memories to avoid psychological distress. The client’s inability to remember possible sexual abuse, despite related behaviors, indicates that these memories might be pushed out of conscious awareness as a protective mechanism.
A: Regression involves reverting to earlier developmental behaviors when stressed, which does not relate to memory suppression as shown here.
B: Projection attributes one’s own unacceptable feelings to others, unlike the client’s internal memory loss.
C: Denial is refusing to accept reality, but the client’s partial memory suggests unconscious blocking, not outright refusal.
The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
Rationale:
The most important client outcome to include is "Demonstrates effective ways to cope with anxiety." This focuses on the client’s ability to manage anxiety independently, directly addressing the behavior of scratching wrists as a maladaptive coping mechanism. Empowering the client with coping skills promotes long-term emotional regulation and reduces self-harm, which is essential for meaningful improvement in mental health.
A: Participates in individual and group therapy supports treatment but does not guarantee the client acquires practical coping skills needed to reduce anxiety-induced scratching independently.
C: Takes all antianxiety medications as prescribed ensures compliance but overlooks teaching the client adaptive anxiety management strategies crucial for behavioral change.
D: Learns methods of relaxation to reduce anxiety offers useful techniques but may not encompass a comprehensive approach to coping, limiting the client’s overall ability to manage stress effectively.
The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?
Rationale:
The client will record episodes of angina and self-management for one week.
This outcome enables monitoring of chest pain patterns and the effectiveness of self-care strategies, providing essential data for timely treatment adjustments. It supports client engagement, symptom recognition, and communication with healthcare providers, crucial for managing hypertension-related angina and preventing complications through proactive symptom tracking and intervention planning.
A: Calling weekly offers general oversight but lacks detailed symptom tracking and immediate client involvement in self-care, limiting timely response to angina episodes and lessening personalized management accuracy.
B: Encouraging daily walking promotes cardiovascular health but does not directly address immediate chest pain management or symptom documentation necessary for effective angina care.
C: Taking up to 4 nitroglycerine tablets sublingually exceeds safe dosing limits and risks adverse effects, making it an unsafe and inappropriate management plan for chest pain.
Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse. The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with: Fatigue, Generalized weakness, Muscle cramps, Tingling sensation in her arms and legs, Lightheadedness. She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Muscle cramps
B
Tingling sensation in her arms and legs
C
Lightheadedness
D
Fatigue
E
Generalized weakness
Rationale:
Muscle cramps, tingling sensation in her arms and legs, and lightheadedness require immediate follow-up by the nurse. These symptoms indicate possible electrolyte imbalances and uremia from missed dialysis, which can lead to life-threatening complications such as cardiac arrhythmias or neurological issues in a patient with end-stage renal disease. Prompt intervention is critical.
D: Fatigue is a common symptom in chronic illness and missed dialysis but is less immediately life-threatening compared to other signs requiring urgent assessment and treatment.
E: Generalized weakness often reflects chronic disease effects or poor nutrition and does not necessitate immediate action unless accompanied by acute distress or other urgent symptoms.
A young adult client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
Rationale:
The client's serum lithium levels should be routinely evaluated.
Routine monitoring of serum lithium levels is essential to ensure therapeutic effectiveness and prevent toxicity, especially during significant life changes like moving away for college. Lithium has a narrow therapeutic window, and factors such as stress, diet, and hydration can alter levels, making regular evaluation crucial for safety and maintaining mood stability in bipolar disorder management.
A: The client should be aware of the signs and symptoms of his illness. This knowledge is important but secondary to immediate safety concerns related to medication monitoring and potential toxicity.
B: The client should plan to participate in group or individual therapy while at college. Therapy is beneficial, but it does not address the critical need for medication level monitoring during this transition.
C: Despite the illness, the client should be able to live away from home. This statement overlooks the importance of close medical supervision, particularly lithium level assessments, which are vital for safe independent living.
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
Rationale:
Focusing on small achievable tasks, not taxing problems, helps the client manage depression by breaking down overwhelming issues into manageable parts, fostering a sense of accomplishment and reducing feelings of helplessness. This strategy promotes gradual progress and builds coping skills without causing additional stress or avoidance behaviors, aligning with the client's current inability to handle personal circumstances.
A: Concentrate on and ventilate emotions when distressed. This may intensify negative feelings and overwhelm the client, who is already struggling with communication and avoidance. Emotional ventilation might not provide practical steps to improve coping or reduce depressive symptoms.
B: Shift attention from self to the needs and requests of others. Redirecting focus outward may increase stress by adding responsibilities, potentially exacerbating depression symptoms rather than supporting the client’s current limited capacity for managing personal issues.
C: Relax and reduce the amount of effort to solve the problem. Reducing effort might promote avoidance rather than active coping, which does not address the client's inability to handle circumstances or encourage constructive problem-solving strategies.
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?
Rationale:
Stimulation and dilated pupils are expected observations in a client who uses cocaine. Cocaine is a central nervous system stimulant that increases sympathetic activity, leading to heightened alertness, increased heart rate, and pupil dilation. These physiological effects correspond with the drug’s stimulant properties, distinguishing it from depressant substances and indicating acute intoxication during assessment.
A: Bradycardia and bradypnea reflect decreased heart and respiratory rates, typical of depressants, not stimulants like cocaine, which elevate these vital signs through sympathetic activation.
C: Hallucinations and delusions are more characteristic of severe psychosis or prolonged drug abuse, not the immediate, typical effects seen in cocaine use.
D: Lethargy and depression indicate central nervous system depression, contrary to cocaine’s excitatory, stimulating impact on mood and energy levels.
Which of the following physician's orders requires priority attention from the nurse? Select all that apply.
Rationale:
Chest X-ray and place on a continuous cardiac monitor require priority attention from the nurse. These orders are critical for immediate assessment and monitoring of potentially life-threatening conditions such as respiratory distress or cardiac arrhythmias, necessitating prompt implementation to guide urgent clinical decisions and interventions that directly impact patient stability and outcomes.
A: Basic metabolic panel focuses on electrolyte and metabolic status, which, while important, does not demand immediate action compared to urgent cardiac or respiratory assessments.
B: Echocardiogram provides detailed cardiac imaging but is less urgent than continuous monitoring or diagnostic chest imaging in acute situations.
C: CT scan of abdomen is important for abdominal pathology but typically not as time-sensitive as cardiac or respiratory monitoring.
D: Blood cultures times 2 sets are essential for infection diagnosis but can be collected after stabilizing critical cardiopulmonary functions.
G: CBC measures blood components but is routine and not immediately critical compared to respiratory or cardiac emergencies.
What treatments should the nurse anticipate for the client at this time? Select all that apply.
Rationale:
The nurse should anticipate scheduling for hemodialysis immediately, checking blood glucose level, drawing a repeat potassium level, holding Lisinopril, and administering insulin, dextrose 50%, and calcium gluconate followed by a repeat 12-lead EKG.
Scheduling hemodialysis is essential for rapid removal of toxins and potassium in severe cases. Checking glucose prevents hypoglycemia during treatment. Repeating potassium confirms hyperkalemia severity. Holding Lisinopril avoids worsening potassium levels. Insulin, dextrose, and calcium gluconate stabilize cardiac membranes and shift potassium intracellularly, while EKG monitors arrhythmias.
A: Call and give a report immediately Calling does not directly treat the client’s critical electrolyte imbalance or initiate urgent interventions necessary for stabilization and reversal of life-threatening conditions.
B: Administer loop diuretic Loop diuretics take longer to reduce potassium and are less effective than immediate hemodialysis or insulin therapy in rapidly managing severe hyperkalemia.
The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
Rationale:
Washes the radiation site with antibacterial soap and water.
Using antibacterial soap on the radiation site can cause irritation and disrupt the skin’s natural barrier, leading to increased sensitivity and potential infection. Gentle cleansing with mild, non-irritating soap is recommended to protect the fragile skin undergoing radiation therapy and promote healing without exacerbating damage or dryness at the portal site.
A: Applies prescribed lotions to the radiation site. Applying prescribed lotions soothes and hydrates the skin, aiding in maintaining moisture and reducing discomfort caused by radiation without compromising treatment effectiveness.
C: Wears clothing to cover the radiation site. Covering the site shields the irradiated skin from external irritants and UV exposure, preventing further damage and promoting healing during radiation therapy.
D: Dries the area with patting motions after taking a shower. Patting the skin dry minimizes trauma and irritation, protecting delicate tissues from friction and abrasion common with rubbing, supporting skin integrity during treatment.
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
Rationale:
The nurse should instruct the client to report when hematuria becomes pink-tinged. This indicates a change from expected post-procedure bleeding to potential abnormal bleeding, signaling the need for medical evaluation. Monitoring hematuria color helps detect complications early after TUNA, ensuring timely intervention and preventing worsening conditions related to excessive bleeding or infection.
A: Use an incentive spirometer supports lung function but does not directly address post-TUNA urinary or bleeding concerns, making it irrelevant to discharge instructions for BPH treatment.
B: Monitor the urinary stream for the decrease in output overlooks that initial urinary changes are expected; focus is on bleeding changes rather than urinary volume unless obstructed.
D: Restrict physical activities is vague; specific activity limitations are not emphasized post-TUNA, unlike monitoring bleeding signs which are critical for safe recovery and complication prevention.
For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
This diagnosis means that I am crazy.'
B
I can learn to manage my thoughts better through therapy.'
C
I can use holistic approaches like meditation to help my symptoms.'
D
Many people have the same response to a stressful situation as I am having right'
E
I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
F
I will probably need to be on medication for the rest of my life.'
Rationale:
This diagnosis means that I am crazy. Many people have the same response to a stressful situation as I am having right. I can use holistic approaches like meditation to help my symptoms. I will probably need to be on medication for the rest of my life.
A: This statement reflects a stigmatizing misconception about mental health diagnoses that requires correction to promote accurate understanding and reduce self-stigma in clients.
B: This statement shows appropriate insight regarding therapy’s role in managing thought patterns, indicating no immediate need for further nurse-led teaching.
C: While holistic approaches can be beneficial, relying solely on them without integrating evidence-based treatments necessitates additional nurse clarification to ensure comprehensive care.
D: This statement incorrectly normalizes stress responses, which might prevent recognizing when symptoms require professional intervention, thus needing further educational follow-up.
E: The linkage between acute stress disorder and high risk for PTSD is not absolute, so this statement does not require immediate corrective teaching from the nurse.
F: This assertion about lifelong medication dependency reflects misunderstanding of treatment variability and prognosis, warranting nurse intervention to provide accurate medication education.
An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?
Rationale:
Agitation, sweating, and abdominal cramps are typical symptoms of narcotic withdrawal and should be documented by the nurse. These signs reflect the body's reaction to the absence of opioids, causing autonomic hyperactivity and gastrointestinal distress. Recognizing these symptoms aids in appropriate management and monitoring of withdrawal in a postoperative adolescent with a history suggestive of opioid use.
A: Vomiting, seizures, and loss of consciousness represent severe complications not commonly associated with early narcotic withdrawal but rather with overdose or other acute conditions.
C: Depression, fatigue, and dizziness indicate general malaise but lack the autonomic and gastrointestinal features characteristic of opioid withdrawal symptoms.
D: Hypotension, shallow respirations, and dilated pupils contradict typical withdrawal, as opioid withdrawal usually causes hypertension, increased respiration, and pupil dilation is not typical.
The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
Rationale:
The nurse should first explore changes in life that have occurred after the loss. This action helps the nurse understand the client’s current emotional state and identify specific stressors or challenges, providing a foundation for tailored support and interventions to address the client’s difficulty in controlling emotions and persistent sadness following the significant loss.
B: Suggesting a psychiatric consultation prematurely may overlook the client’s immediate emotional needs and the importance of initial assessment before more intensive interventions are considered.
C: Offering pastoral counseling without first assessing the client’s emotional and situational context could miss critical psychological or social factors requiring attention.
D: Encouraging support group attendance initially may not address the client’s personal grief process or immediate emotional distress, which require individualized exploration first.
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
Rationale:
The most important nursing intervention is to alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation.
Close monitoring allows for immediate intervention during heightened tension and pacing, preventing self-harm. Continuous observation is crucial for safety, as it helps staff recognize escalating behaviors and provide timely support, decreasing the likelihood of injury in clients with a history of self-mutilation.
A: Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm. This action alone does not address the immediate behavioral signs requiring active intervention and supervision.
B: Provide the client time alone in the client’s room to reduce external stimulation and promote relaxation. Isolation may increase anxiety or feelings of abandonment, potentially worsening self-harming impulses rather than calming the client.
D: Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed. Setting limits is important but insufficient during acute tension without direct monitoring to prevent imminent self-harm.
A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?
Rationale:
Direct Answer: Plan a list of activities to be carried out daily.
Correct Option Explanation: Planning a daily activity list helps structure the client’s time, reducing compulsive behaviors by promoting engagement and improving time management. This intervention supports functional ability and decreases anxiety linked to obsessive-compulsive actions, facilitating gradual behavior modification and fostering independence in managing daily responsibilities effectively.
A: Ask the client why she checks the locks. This approach may provoke defensiveness and fails to address functional impairment or provide immediate strategies to reduce compulsive rituals affecting daily functioning.
B: Determine the type and size of the locks. Focusing on physical details of locks ignores psychological aspects and does not intervene in the compulsive behavior or improve the client’s time management challenges.
C: Discuss checking the time frequently. The client’s issue relates to compulsive checking of locks, not time-checking behaviors; this option misdirects attention and does not directly address the primary compulsive actions.
When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, 'What took you so long to get in here!' Which action should the nurse implement?
Rationale:
The nurse should provide for personal space. Maintaining personal space helps reduce the client's agitation by preventing feelings of threat or invasion, which can escalate aggressive behaviors. Respecting boundaries promotes a calmer environment, allowing the nurse to assess the situation safely and effectively while minimizing confrontation and potential harm to both client and staff.
A: Request backup from the staff. Although helpful in dangerous situations, immediate backup may escalate the client’s agitation rather than de-escalate, especially if the client perceives the response as confrontational or punitive.
B: Stand in the doorway. Standing in the doorway can block the client’s exit, increasing feelings of confinement and frustration, potentially intensifying aggressive behavior instead of promoting calmness and cooperation.
D: Encourage the client to sit down. Prompting the client to sit may be perceived as controlling or demanding, which can provoke further resistance or hostility rather than helping the client regain composure peacefully.
Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
Rationale:
Discuss the client's suicide plan, encourage the client to discuss thoughts and feelings about wanting to die, and reinforce statements regarding a will to live and realistic plans for the future. These interventions directly address suicidal ideation by promoting open communication, assessing risk, and fostering hope, which are critical in safely managing adolescent depression and preventing self-harm or suicide attempts.
A: Restrict visitors to family members only. This limits social support unnecessarily and may increase feelings of isolation, which can worsen depression rather than aid recovery or safety.
C: Limit time allowed to play video games. This does not directly address depressive symptoms or suicide risk and may overlook the therapeutic value some adolescents find in gaming as a coping mechanism.
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
Rationale:
Developing a plan for daily structured activities is likely most effective in returning the client to normal functioning. Structured activities help counteract psychomotor retardation by promoting regular engagement, improve motivation through achievable goals, and regulate sleep-wake cycles, addressing hypersomnia. This approach fosters routine, enhances mood, and gradually restores functional abilities disrupted by major depressive disorder.
B: Encourage the client to exercise. Exercise benefits mood and energy but may be too demanding initially for someone with psychomotor retardation and low motivation, limiting its immediate effectiveness in restoring function.
C: Suggest that the client develop a list of pleasurable activities. Listing pleasurable activities fosters positive focus but lacks the structured implementation needed to overcome psychomotor slowing and hypersomnia in major depression.
D: Provide education on methods to enhance sleep. Sleep education addresses hypersomnia partially but does not tackle psychomotor retardation or motivation deficits, making it insufficient as a comprehensive intervention alone.
The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?
Rationale:
The nurse should ask the mother if she has ever thought about harming herself or her child. This response prioritizes safety by assessing potential risk of harm, which is crucial given the mother’s expressed depression and feelings of hopelessness about her child's future. Early identification of suicidal or harmful ideation allows timely intervention and support to prevent possible tragedy.
A: Encourage the mother to write thoughts and feelings in a journal does not address immediate safety concerns or assess risk of harm, making it an insufficient initial response to severe depressive symptoms.
B: Determine if the mother has other children who do not have developmental disabilities diverts focus away from her current emotional state and potential risk factors, lacking relevance to her expressed depression.
C: Reassure the mother that her child will achieve some growth and development milestones ignores the mother’s feelings of hopelessness and overlooks the need to evaluate her mental health and safety risks.
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. The nurse engages the client in conversation about her feelings and some of her coping mechanisms. Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
The client discusses moving to Hawaii instead of returning to rebuild her house. (Fantasy)
B
The client seems unemotional when talking about needing to rebuild her house. (Isolation)
C
The client states that she sometimes forgets why she is in the hospital. (Suppression)
D
The client is frightened that the hospital will burn down. (Denial)
Rationale:
The client discusses moving to Hawaii instead of returning to rebuild her house. This statement exemplifies fantasy, a defense mechanism where the client escapes reality by imagining a more desirable situation, avoiding the distressing reality of rebuilding after loss. It reflects a mental diversion to cope with overwhelming emotions related to the hurricane’s impact and personal trauma.
B: The client seems unemotional when talking about needing to rebuild her house. This reflects isolation, separating feelings from facts, not fantasy, as it involves detaching emotional responses rather than imagining alternative realities.
C: The client states that she sometimes forgets why she is in the hospital. This illustrates suppression, a conscious effort to avoid distressing thoughts, unlike fantasy which is an unconscious mental escape into imagined scenarios.
D: The client is frightened that the hospital will burn down. This represents denial, refusing to accept reality, differing from fantasy, which involves creating positive imagined alternatives rather than rejecting facts.
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
Rationale:
The best intervention is to assist the client with relaxation techniques in the group. Relaxation methods help reduce physiological symptoms of severe anxiety promptly, allowing the client to regain control while remaining within the therapeutic environment. This approach supports immediate calming without isolating the client, maintaining group cohesion and promoting coping skills during heightened anxiety episodes.
A: Ask the client to describe and identify the source of the feelings delays immediate anxiety relief and may increase distress, as severe anxiety often impairs cognitive processing and verbalization at that moment.
B: Provide education about ways to cope with anxiety lacks immediacy in severe episodes, as clients require direct intervention to alleviate symptoms before learning coping strategies.
D: Escort the client from the group to reduce stimuli removes social support and may reinforce avoidance, preventing exposure-based coping and potentially increasing isolation during critical anxiety moments.
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?
Rationale:
Cocaine use causes stimulation and dilated pupils due to its stimulant effects on the central nervous system. It increases heart rate, alertness, and pupil size by activating the sympathetic nervous system. These signs are typical during intoxication, helping nurses identify recent cocaine use. The assessment focuses on physiological and neurological indicators consistent with stimulant exposure rather than depressant or psychotic symptoms.
B: Bradycardia and bradypnea manifest as slowed heart and respiratory rates, which contradict the stimulant effects of cocaine that typically accelerate these functions rather than reduce them.
C: Hallucinations and delusions primarily occur with severe psychosis or certain drug intoxications, but are not standard acute manifestations of cocaine use, which mostly causes heightened alertness and physical stimulation.
D: Lethargy and depression reflect central nervous system depression, opposite to cocaine’s stimulant properties that increase activity, energy, and pupil dilation instead of causing diminished responsiveness.
Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?
Rationale:
The best approach for the nurse to use when interviewing a client about suicidal ideations is to begin with questions that are less sensitive in nature.
Starting with less sensitive questions helps build rapport and trust, allowing the client to feel more comfortable and open. This gradual approach facilitates a more honest and thorough disclosure, making it easier to explore deeper, more difficult topics like suicidal thoughts without causing immediate distress or defensiveness.
A: Share personal values to put the client at ease Sharing personal values can impose bias and may hinder objective assessment, potentially making the client feel judged rather than supported.
B: Ask questions in a vague, non-specific format Vague questioning can lead to unclear responses and missed critical information, which is detrimental when assessing suicidal risk and the client’s mental state.
D: Get the most difficult questions over with first Introducing difficult questions abruptly may increase anxiety and resistance, reducing the likelihood of honest communication and trust-building during the interview.
Following involvement in a motor vehicle collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?
Rationale:
Lorazepam 2 mg IM should be administered if the client begins to exhibit signs of delirium tremens (DTs).
Lorazepam is a benzodiazepine that effectively manages DTs by reducing agitation, seizures, and autonomic instability. It acts on the central nervous system to enhance GABA activity, calming withdrawal symptoms and preventing complications associated with alcohol withdrawal in critically ill patients.
A: Prochlorperazine 5 mg IM Treats nausea and vomiting but lacks efficacy in managing withdrawal symptoms or preventing seizures associated with DTs.
B: Hydromorphone 2 mg IM Provides pain relief but does not address the neurological or autonomic symptoms of delirium tremens.
D: Chlorpromazine 50 mg IM An antipsychotic that may worsen DTs by lowering seizure threshold and is not recommended for alcohol withdrawal management.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?
Rationale:
The nurse should explore efforts to cut down, annoyance with questions, guilt, and drinking as an 'Eye-opener' based on the CAGE questionnaire. This tool specifically assesses these four areas to identify potential alcohol dependence by focusing on behavioral and emotional responses related to drinking, making it effective for initial screening in clients concerned about their alcohol use patterns and consequences.
B: Consumption, liver enzyme, gastrointestinal complaints, and bleeding involve medical and physical symptoms not targeted by the CAGE tool, which centers on psychological and behavioral indicators of alcohol problems rather than clinical diagnostics or lab results.
C: Cancer screening results, anger, gastritis, and daily alcohol intake include unrelated health screenings and emotional states that the CAGE questionnaire does not address, as it focuses on specific drinking-related behaviors and feelings to detect alcohol misuse.
D: Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake reflect broader behavioral and social consequences but miss key CAGE elements like annoyance and eye-openers, which are essential for this tool’s diagnostic focus.
The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
Rationale:
Demonstrates effective ways to cope with anxiety best addresses the client’s underlying issue and promotes long-term management beyond symptom relief. This outcome directly targets the behavior driving self-injury by equipping the client with practical skills to handle anxiety, reducing the need for harmful coping mechanisms and fostering emotional resilience and self-control in stressful situations.
A: Participates in individual and group therapy focuses on treatment settings but does not ensure the client acquires coping skills or reduces anxiety-driven behaviors independently.
C: Learns methods of relaxation to reduce anxiety centers on symptom relief but may not fully equip the client to handle anxiety triggers or prevent self-harm behaviors.
D: Takes all antianxiety medications as prescribed emphasizes medication adherence yet overlooks skill development essential for managing anxiety without reliance solely on pharmacological treatment.
A male client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
Rationale:
Routine evaluation of the client's serum lithium levels is most important to ensure therapeutic effectiveness and prevent toxicity while managing bipolar disorder.
B: Lithium has a narrow therapeutic range requiring regular monitoring to avoid toxicity or subtherapeutic levels, essential for safe medication management and symptom control in bipolar disorder patients.
A: Group or individual therapy benefits mental health but does not address the immediate safety concerns related to lithium medication management.
C: Awareness of illness symptoms aids self-management but does not replace the critical necessity for lithium level monitoring.
D: Living away from home depends on stability and treatment adherence, not solely on the presence of bipolar disorder.